We at the Ocean Hyperbaric Center wish to afford you the best possible care for your problem(s). In order to help us would you please fill out the following questionnaire. This will aid us to make proper medical decisions regarding your treatment.
Name:
*
Date:
*
Chief Complaint (your main complaint):
History of present illness (tell us about it: how long have you had it, how it started, what you are taking to make it better, what doctors have you seen?):
When was your last:
Complete Physical
Chest X-ray
EKG
Past Medical History (what other illnesses have you had? Have you had surgery? Have you ever been in the hospital? When did you see a health professional?
SYSTEM REVIEW
(Tell us about any symptoms referable to any part of the body): If the answer to any of these is yes please check and give approximate duration of these symptoms.
HEAD
Double vision
yes
No
Dizzines
Yes
No
Fainting
Yes
No
Ringing of the ears
Yes
No
Hardening of the arteries
Yes
No
Weakness in the extremities Brief or lasting
Yes
No
Stroke
Yes
No
Do you wear glasses
Yes
No
Headache
Yes
No
Emphysema
Yes
No
NOSE
congestion
Yes
No
sinus problems
Yes
No
deviated septum
Yes
No
facial injury
Yes
No
bleeding
Yes
No
LUNGS
shortness of breath
Yes
No
Cough
Yes
No
Asthma
Yes
No
HEART
enlargement
Yes
No
shortness of breath
Yes
No
swelling of the ankles
Yes
No
chest pain
Yes
No
angina
Yes
No
skipped beat
Yes
No
hypertension
Yes
No
Cholesterol
Yes
No
Heart murmur
Yes
No
EARS
Ringing
Yes
No
Submit
Should be Empty: